Clinical Research on Foot & Ankle Sadeghi-Demneh, Clin Res Foot Ankle 2015, 3:2

http://dx.doi.org/10.4172/2329-910X.1000170

Research Open Access

The Effect of Transcutaneous Electrical Nerve Stimulation (TENS) Applied to

the Foot and Ankle on Strength, Proprioception and Balance: A Preliminary
Study
Ebrahim Sadeghi-Demneh1,2*, Sarah F Tyson1,3 , Christopher J Nester1 and Glen Cooper4
1School of Health Sciences, University of Salford, Salford, UK
2Musculoskeletal Research center, Isfahan University of Medical Sciences, Isfahan, Iran
3Stroke and Vascular Research Centre, University of Manchester, Manchester, UK
4School of Engineering, Manchester Metropolitan University, UK
*Corresponding author: Ebrahim Sadeghi-Demneh, School of Health Sciences, University of Salford, Salford UK, Tel: +98 311 792 2021; Fax: +98 311 6687270; E-
mail: sadeghi@rehab.mui.ac.ir
Received date: Jun 13, 2015, Accepted date: Aug 03, 2015, Published date: Aug 07, 2015
Copyright: 2015 Sadeghi-Demneh E, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Background: Transcutaneous electrical nerve stimulation (TENS) promotes upper motor neuron excitability
which has the potential to improve function. As a precursor to clinical trials, we investigated the potential efficacy of
TENS on strength, proprioception and balance in healthy older adults.

Method: Design: A paired-sample randomized crossover trial. No stimulation was the control. Intervention: A
one-off session of TENS (Modulated frequency: 70-130Hz, 5 second cycle) via a conductive sock. Participants: 25
healthy older volunteers with no pre-existing balance or mobility limitations or contra-indications to TENS.
Outcomes: Dorsiflexor and plantarflexor strength and proprioception using an isokinetic dynamometer and balance
(postural sway and forward reach test). Analysis: Paired t-tests

Results: None of the parameters showed any significant changes with TENS (p>0.05).

Conclusions: The stimulation of cutaneous sensory nerve endings of the foot with the application of TENS
showed no immediate effect on the ankle proprioception, lower leg muscle strength, and postural stability. The
concern that TENS would have a distracting impact on sensation and balance was not supported according to these
results.

Keywords: Transcutaneous electrical nerve stimulation; Strength;
Proprioception; Balance
Introduction
Transcutaneous electrical nerve stimulation (TENS) is a well-
known intervention which differentially influence a variety of
outcomes related to pain [1-3]. Physical function used to be part of
this outcome domain [4]. It has been shown that TENS increased the
balance function on the Timed up and GO test as well as reducing
the pain level in people with osteoarthritis [5], but it was unclear if this
improvement is related to the pain reduction effects or direct
promotion of functional outcomes using TENS. This has led to the
intriguing notion that TENS could be used to promote motor
performance or recovery in people with disabling neuromotor
conditions. Cortical excitability changes can alter the individual
experience to interact with the environment. The new situation can
result in either an improvement or detrimental effects on the
functional performance [6]. There is some evidence that TENS to the
lower limb can enhance gait speed, functional recovery, spasticity and
reflex activity in people with stroke [7,8], joint position sense in people
with knee osteoarthritis [9] and postural sway in healthy volunteers
[10-13].
Foot and ankle complex is the only segment which is in direct
contact with supporting surface and has an important role in
collecting somatosensoy feedbacks and regulating balance control [14].
Sensory impairements in the foot and ankle complex contribute to
balance and activity probles in people with stroke [15]. Acessory
sensory stimulation applied to the paretic hand improves the upper
limb function in people with stroke [16]. If effective, the application of
TENS at the foot and ankle has the potential to be a highly beneficial
intervention as deficits of strength, joint position sense and balance
control contribute to the increased risk of falls and limited mobility
associated with older adults and many neurological conditions [17,18].
There is another debate that stimulation can be a distraction for people
while they need their attention for keeping the balance and walking
safe. Accordingly, it remains a major concern if applied TENS to the
foot has any adverse effects on the balance parameters and how the
people with disabling neurologic conditions would cope with this
detrimental effect. To take this ethical issue into account, a priliminary
study was needed to carry out with age-matched healthy controls.
Augmenting plantar sensory feedbacks provides a potential
mechanism to improve balance stability, even in the healthy subjects
[19]. This exploratory trial was to check the components of the
intervention and define the feasibility of a safe testing protocol
according to the UK Medical Research Council Framework (MRC) for
the evaluation of complex interventions [20]. Thus, as a precursor to

Clin Res Foot Ankle Volume 3 Issue 2 1000170

ISSN:2329-910X CRFA, an open access
Citation: Sadeghi-Demneh E, Tyson SF, Nester CJ, Cooper G (2015) The Effect of Transcutaneous Electrical Nerve Stimulation (TENS) Applied
to the Foot and Ankle on Strength, Proprioception and Balance: A Preliminary Study. Clin Res Foot Ankle 3: 170. doi:
10.4172/2329-910X.1000170

Page 2 of 5

trials in patient populations, we investigated the effect of TENS in which they may, or may not, be able to feel without specifying which
healthy older adults who are assumed to have a lesser risk of falls we thought may be the more effective.
within the testings compared with people with neurologic problems.
To our knowledge, none of other studies applied the TENS at the foot
and ankle in healthy subjects. It was hypothesized that applying TENS
to the foot and ankle complex would improve the balance and postural
control. The aim of this study was to investigate any possible effects of
TENS on balance control and its possible underlying mechanisms in
the lower leg like proprioception [21,22] and muscle strength [23].

Method
A paired sample, randomized crossover trial of the immediate
effects of TENS was used in which the participants acted as their own
control and the randomization came from the order in which the
TENS or control was given. All participants completed both control
and stimulation conditions and all testing procedures. Ethics approval
was obtained from the University of Salfords Research Ethics Figure 1: The conductive sock (left); and TENS unit (right).
Committee (Manchester, UK).

Participants
Testing protocol
We recruited a convenience sample of healthy volunteers from staff
All testing was completed in a single session at the Universitys
in the university and friends and relatives of stroke survivors who
clinical research facility. After informed consent was obtained, the
attended local community stroke groups and/or were on the
socks and TENS machine were applied and the participant was
Rehabilitation Research Groups database of study volunteers.
randomized (by them selecting a concealed envelope from a bag) to
Participants were over 50 years old, able to consent and had no
receive the stimulation or the control condition first. Then they moved
conditions limiting balance or mobility or contradictions to TENS to
around and familiarized themselves with the stimulation. When they
the leg (cardiac pacemaker or skin lesions over the lower leg).
felt comfortable and confident the following testing protocol was
undertaken. The order of testing was randomized to avoid order
The intervention effects. Participants were free to move around or rest at their
TENS was delivered using a Biostim M7 TENS unit (Biomedical convenience during and between testing. For all parameters, the test
Life Systems, Princeton, USA) with a conductive sock that stimulates was explained and demonstrated to the participant who then practiced
the whole foot and ankle (iSock, TensCare Ltd, Surrey, UK) (Figure 1) until they felt comfortable.
on both feet. As this study was aimed to check the feasibility of the
testing protocol for hemiplegic people, only the right foot was Proprioception and strength
connected to the TENS machine (in all participants right foot was the
Proprioception and strength of the right leg were tested with a
dominant side) and proprioception and strength were tested in the
Biodex Isokinetic Dyanamoeter (Figure 2B), using standard operating
right leg. The socks manufacturer recommends that it should be
instructions [18,24,25]. Movement detection threshold was measured
dampened to maximize conductivity of the stimulation. However,
as an outcome to evaluate proprioception at the ankle joint. The tests
pilot work showed that it was impossible to standardize the degree of
were repeated six times (three in each direction) and mean values
dampness. Some participants found it unacceptable to wear a damp
calculated. Joint movement detection of the ankle was assessed in
sock inside their shoe, so the sock was used in a dry condition if they
dorsiflexion and plantarflexion; the participants ankle was passively
felt the stimulation on the foot. A biphasic symmetrical stimulus with
moved from neutral into dorsiflexion or plantarflexion at 0.25/s (to
pulse duration of 50s and ranging frequency of 70-130Hz over a 5
avoid any stretch on peri-articular structures and reduce cues from the
second cycle was used. This frequency modulation was to prevent
footplate). Proprioception was tested with vision occluded. They
habituation and cover the optimal frequency for all participants, which
indicated when they detected the movement using a handheld trigger
is specific to each individual but is around 100 Hz. Intensity of
that recorded the angle and verbally indicated the direction of
stimulation was increased until participant reported a gentle tingling
movement. Maximum isometric plantarflexor and dorsiflexor strength
over their foot and/or ankle without pain or muscle activation. As the
was assessed with the ankle in a neutral position (90 degrees). For
objective was to evaluate the effects of TENS during activities, the
plantarflexion, participants pressed their foot as hard as possible
duration of the stimulation was not specified, but participants were
against the footplate and then pulled it upward as strongly as possible
encouraged to use it until they felt comfortable and had got used to
(dorsiflexion).
the sensation then we tested them while stimulated. Equally, when
tested without the stimulation (the control condition) participants
indicated when they felt the stimulation had worn off and were then Balance
tested. For the control treatment, the sock and TENS was applied in Postural stability was measured as a parameter of balance function.
the same way and the machine was turned on but no stimulation was It was measured during barefoot standing over an AMTI (Advanced
given. To blind the participants as far as possible to the treatment Medical Technology Inc.) forceplate (AMTI Inc., Watertown, USA)
received they were told that they would receive two types of signal with a sampling rate of 100 Hz. During the postural stability testing,

Clin Res Foot Ankle Volume 3 Issue 2 1000170

ISSN:2329-910X CRFA, an open access
Citation: Sadeghi-Demneh E, Tyson SF, Nester CJ, Cooper G (2015) The Effect of Transcutaneous Electrical Nerve Stimulation (TENS) Applied
to the Foot and Ankle on Strength, Proprioception and Balance: A Preliminary Study. Clin Res Foot Ankle 3: 170. doi:
10.4172/2329-910X.1000170

Page 3 of 5

participants were asked to put their feet on the marked area (feet were
apart and slightly turned out), arms relaxed at their sides and looking
straight forward at a reference picture on the wall in front of them
(Figure 2A). They were asked to maintain a quiet standing position for
40 seconds with and without the stimulation in two different standing
conditions tested in a random order: 1) standing
Figure 2: Testing protocol included A) Postural stability test; B)
Measurements of ankle proprioception and plantar and dorsi
flexors strength using Biodex system; and C) forward reach test.
The statistical analyses were carried out using SPSS version 17.
Paired t-test compared the outcome measures with and without TENS.
Level of significance was at 0.05.
Results
Twenty-five healthy volunteers (12 women and 13 men; age 56.8
14.5 years; weight: 78.6 14.5 Kg; height: 171.2 6.7 cm) were
recruited. All tolerated the TENS which had no significant effect
(either positive or negative on any of the parameters measured) (Table
1).
As none of the study outcome measures showed a significant
change with and without stimulation, a power analysis was undertaken
(using GPower Software 3.1) to explore the impact of the small sample
size on the result. Mean velocity of CoP was selected as the
representative parameter for this analysis as it had been shown to be
the more reliable and sensitive measure of postural sway [29]. The
power of the current study was acceptable [power (1- error
prob)=0.85]. Alpha level was adjusted at 0.15 rather than traditional
level of .05, as recommended for small group size [30].
Outcome Measure Mean SD P-values (95% CI)

Mean Velocity of CoP (mm/s) Control=15.2 5.9

0.281 (-1.7, 0.85)
with open eyes and 2) standing with closed eyes. Three trials were (Open-eyes) TENS =15.4 4.7
recorded for each participant to be averaged and produce a
Mean Velocity of CoP (mm/s) Control=23.3 11.9
representative value for their postural sway. The forceplate had been (Closed-eyes) TENS=24.4 11.5
0.884 (-2.5, 0.59)
calibrated and reset before each testing to remove the offset signals.
Between each repetition, the participants were allowed to have a two- Forward Reach (cm)
Control=26.7 7.9
0.738 (-2.3, -3.2)
minute break to prevent fatigue. TENS=26.2 6.7

The Standing Forward Reach Test evaluated balance activity [26] by Plantarflexor strength Control=54.3 25.3
0.139 (9.6, 1.45)
(Newton/m) TENS=58.4 25.3
measuring the distance participant could reach beyond arms length
was measured with a yardstick set at the participants shoulder height Dorsiflexor strength Control=21.5 9.8
0.179 (-0.6, -3.2)
(Figure 2C). The first data were collected as a practice run and then (Newton/m) TENS=20.2 10.9
the test was repeated three times and means values calculated [27].
Control=1.58 0.96
JPS -Plantarflexion (degrees) 0.182 (0.65, 0.13)
TENS=1.84 0.9
Data processing and analysis
Control=2.66 2.32
JPS -Dorsiflexion (degrees) 0.207 (0.27, 2.92)
The recorded force plate signals were quantified prior to statistical TENS=2.2 1.6
analysis. Postural sway was defined as the excursion of the centre of
pressure (CoP) over the force plate [28]. The CoP signals were passed Table 1: The effect of TENS on balance, strength, and proprioception
through a second degree curve filter with a 10 Hz cut-off frequency parameters (SD: Standard Deviation; CI: Confidence Interval; JPS:
(using Qualysis software). The first and last 5 seconds of all trials were Joint Position Sense).
cropped (remaining 30s, 3000 data points per time-series). This was to
remove the effect of possible movement adjustments participants
Discussion
might have done to get situated over the forceplate at the beginning of
tests or when estimating the end of recording time. The acquired CoP The results of this study show no significant impact of TENS on
time-series had two components of antroposterior (AP) and ankle strength, joint position sense or balance control in healthy older
mediolateral (ML) in a coordinated system. The resultant distance adults. This is one of the very few reports of negative findings for
(RD) was calculated from these point measures as following: supplementary sensory stimulation given via TENS or any other
paradigm to healthy or disabled participants. It is impossible to
RD = AP 2 + ML 2 ascertain whether this is merely due to reporting bias where other
researchers have not published non-significant findings or due to
Mean velocity (MV) was the average speed that CoP moves. It is
methodological differences. Previous reports of TENS as a potential
calculated by dividing total excursion of the CoP to the recording time
treatment paradigm in healthy adults used a similar paired-group
(T) [28]:
randomized controlled design so it is unlikely that a different bias
nN=1
1
APn +1 APn 2 + MLn +1 MLn 2 from the trial design is a contributor. However the previous reports on
MV = healthy volunteers used postural sway (a measure of balance
T
impairment) as the primary outcome and gave stimulation to the knee
or posterior calf [8,10,11] to influence the ankle strategy for standing
postural which contrasts our stimulation of the foot and ankle using

Clin Res Foot Ankle Volume 3 Issue 2 1000170

ISSN:2329-910X CRFA, an open access
Citation: Sadeghi-Demneh E, Tyson SF, Nester CJ, Cooper G (2015) The Effect of Transcutaneous Electrical Nerve Stimulation (TENS) Applied
to the Foot and Ankle on Strength, Proprioception and Balance: A Preliminary Study. Clin Res Foot Ankle 3: 170. doi:
10.4172/2329-910X.1000170
strength, proprioception and balance activity outcomes. Further
methodological differences were the involvement of young adults
(university students) who received a similar dose of TENS [8,10] or
older adults who received sub-sensory stimulation [11]. Study
heterogeneity is such that it is not possible to identify methodological
differences to explain the different response to previous trials. One
potentially important difference with previous studies was the method
of delivering the TENS. Using a conductive sock might reduce the
deliverability of the stimulation compared to the gel electrodes. More
recent reports however showed a significant improvement in
functional outcomes using stimulation delivered through the same
sock in people with neurological condition [31,32]. Thus, it is not clear
whether the difference in response is due to heterogeneity in the
participants selected, the stimulation paradigm applied or the outcome
measures used. Similarly, studies of TENS in patient groups are too
heterogeneous in terms of the stimulation protocols, the selected
participants and the outcome measures to postulate hypotheses about
the possible discrepancies of our findings. The TENS effect was
measured during peak effect. This approach was thought to be more
likely to show any possible effect. Previous research demonstrated that
TENS has the greatest effects when it is on or immediately after
switching it off [1,33].
Limitations
This study measured only the immediate effects of short term
stimulation in healthy elders, whether there is any carry-over effect or
whether longer term stimulation is more or less beneficial needs to be
addressed in the future studies. Ankle joint proprioception can be
improved with regular training over a longer time. A recent study has
reported 12 weeks of proprioceptive training is necessary to improve
the balance performance in the young healthy athletes [34]. Results
also indicated that TENS did not show a distracting effect on
proprioception accuracy or a detrimental effect on the balance
performance and muscle recruitment (strength). The application of
weak electrical signals on the foot is assumed to influence mainly
cutaneous sensory nerve endings. Studies have shown that deeper
sensory nerve endings (those placed in ligaments, joint capsule and
particular padding tissue around the ankle) play more important role
in sourcing the ankle proprioception [35,36]. In accordance to this
assumption, a study on people with sural nerve harvesting showed no
change in the detection of their ankle position, muscular refelex time,
and postural stability parameters [37]. The findings can be considered
as an exploratory study to establish a safe testing protocol, which is
defensible for using in people who are at the risk of falls and should
not be challenged with a distracting intervention. This was a ground
work that covered a proof-of-concept to develop a new intervention
[20]. Further research is needed to develop this potential intervention
with subjects who had specific neurological conditions that may be
more responsive to augmented sensory inputs during functional tasks.
Conclusions
In contrast to previous reports of postural control, we found that
TENS did not affect the strength, proprioception and balance in
healthy older volunteers. Further research is needed to systematically
develop this potential intervention.
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